Provider Demographics
NPI:1063435576
Name:MUNDALL, JON EDWIN (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:EDWIN
Last Name:MUNDALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1167
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-1167
Mailing Address - Country:US
Mailing Address - Phone:530-842-9800
Mailing Address - Fax:530-842-9054
Practice Address - Street 1:475 BRUCE ST
Practice Address - Street 2:SUITE 700
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9553
Practice Address - Country:US
Practice Address - Phone:530-842-4445
Practice Address - Fax:530-842-9054
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96027207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine